Your Guide to Giving Birth

From the moment you discover you’re pregnant, decisions await you. Fortunately, many of them, such as what color to paint the nursery and whether to use cloth or disposable diapers, are not life-changing (though they may seem so at the time). But the big-picture decisions—questions like where your baby will be born, who will deliver her and whether or not you should schedule the birth—can have a profound impact on your pregnancy and delivery, often making the difference between a joyous experience you can’t wait to repeat and a traumatic one you’d rather forget. >> We’re here to help, with information to guide you through these and other choices you may be facing, such as whether to get an epidural or to try for a vaginal birth after having a Cesarean. We also provide lots of immediately practical advice, including surprising tips for an easier labor. >> Finally, though no two labor and delivery experiences are exactly alike, our outline of what happens in the final hours of pregnancy can help you prepare for the most exciting day of your life: your baby’s birth day. Wherever you are in your journey toward motherhood, be sure to keep this guide handy.

The hospital

If you have pregnancy complications or risk factors for a C-section, prefer an obstetrician to a midwife or want to receive labor-induction and/or pain medication, a hospital is for you. If your insurance lets you choose, here’s a checklist of what to look for. Keep in mind that very few hospitals meet all these criteria, some of which are, obviously, more important than others.

> An obstetrician is on the premises at all times.

> The hospital’s maternal mortality rate is at or below .01 percent.

> There is a neonatal intensive-care unit of at least level II (level III is best).

> The primary C-section rate is at or below the national average of 26 percent.

> The hospital does not limit when you can receive pain medication.

> The hospital has a lactation consultant on staff.

> Midwives are allowed to deliver babies, and doula services are permitted.

> The same nurses care for you throughout labor, delivery and recovery.

> During labor, women are allowed to walk around and to use private bathtubs or showers. > Women can give birth in rooms specifically geared for labor/delivery, recovery and postpartum.

> There is a place for the father to sleep overnight.

> The baby can stay in your room with you.

> Friends and relatives besides the father are allowed to attend the birth.

> Water births, videotaping of births and massage services are permitted and/or available.

> Classes on infant care, breastfeeding, sibling relationships and the like are offered.

The birth center

Freestanding (nonhospital) birth centers offer women with uncomplicated pregnancies who want a natural delivery a less high-tech, more homelike alternative to hospitals. Babies generally are delivered by midwives, and women are allowed to give birth in the position that’s most comfortable for them. “Birth centers don’t offer epidurals or [the labor-induction drug] Pitocin, and they only take low-risk patients,” says Kate Bauer, executive director of the National Association of Childbearing Centers, based in Perkiomenville, Pa. “What they do offer is time- and education-intensive care from the prenatal period through six weeks postpartum.” According to a recent study in the American Journal of Public Health, most women who plan to give birth at freestanding birth centers end up succeeding, with fewer C-sections and medical interventions. While about 15 percent of women are transferred to a hospital, this is usually because of failure to progress, Bauer says. “Most of these women go on to give birth vaginally,” she adds. Bauer suggests looking for a birth center with the following features:

> The staff are advocates for natural childbirth and breastfeeding.

> An extensive support system is in place.

> The baby can stay in the room with you.

> The center is accredited by the Commission for the Accreditation of Birth Centers. Today, an increasing number of hospitals have on-site birth centers. In these homey, comfortable rooms, your baby will stay with you and, because it will be assumed that you are breastfeeding, won’t be given a bottle. “Some hospitals have adopted certain of the philosophies of our freestanding birth centers, and we think that’s great,” Bauer says.

At home

Most women who want a home birth believe that having a baby is a natural process that requires little medical intervention. Many also want more control and attention than they might get in a hospital or even a birth center. Here’s what you should know: > Home birth isn’t for everyone. Conditions that make a hospital the safer choice include high blood pressure, diabetes, severe anemia, preterm labor, unexplained vaginal bleeding, carrying twins, a pregnancy that goes beyond 42 weeks or a baby in the breech position.

> European studies show that for a healthy woman with a low-risk pregnancy, home birth is a safe option. However, the American College of Obstetricians and Gynecologists main Home-birth resources

>> The International Association of Parents and Professionals for Safe Alternatives in Childbirth, www.napsac.org.

>> A Good Birth, a Safe Birth: Choosing and Having the Childbirth Experience You Want, by Diana Korte and Roberta M. Scaer (Harvard Common Press, 1992).

6 ways to increase your chances of a natural birth

Though statistics are scarce, some approaches are known, at least anecdotally, to increase the odds of having an unmedicated delivery:

1. Use a Midwife

Studies show that using a properly trained, licensed midwife rather than an obstetrician can greatly increase your chances. The extra attention pays off in less anxiety and pain. For referrals: American College of Nurse-Midwives, 202-728-9860, www.midwife.org.

2. Hire a Doula

A doula is a woman trained to provide mothers and their families with encouragement and information through late pregnancy, labor and delivery. A review of six studies of more than 2,000 women found that with the continuous support of a trained doula, epidural use decreased by 60 percent, C-sections by 50 percent, oxytocin use for labor induction by 40 percent, forceps use by 40 percent, and average length of labor by 25 percent. For referrals: Association of Labor Assistants & Childbirth Educators (ALACE), 617-441-2500, www.alace.org; Doulas of North America (DONA), 801-756-7331, www.dona.org; International Childbirth Education Association (ICEA), 800-624-4934, www.icea.org.

3. Practice self-hypnosis

“For a gentle, natural birth, the muscles of your uterus need oxygen-carrying blood,” says Marie Mongan, founder of HypnoBirthing (603-798-3286; www.hypno birthing.com), a program that teaches pregnant women self-hypnosis techniques for use during labor. “Fear directs blood away from the uterus, and the result is more pain.” The American Society of Clinical Hypnosis reports that for about two-thirds of women who use hypnosis, it is their sole analgesic during labor.

4. Learn perineal massage

By relaxing and stretching the area around the vagina during pregnancy, perineal massage may safely help speed delivery, lessening the need for painkillers. Do this for six to eight minutes daily, beginning no earlier than 34 weeks into your pregnancy. (For information: Prenatal Perineal Massage brochure, ICEA, 800-624-4934, www.icea.org.)

5. Take childbirth ed

Several courses focus on unmedicated deliveries. Enroll as early as possible; classes fill up fast, and some, such as Bradley (see pg. 84), run 12 weeks, so you need to start them in your second trimester.

6. Get into warm water

Doing so can naturally facilitate labor and ease pain. You can climb into a tub for a few hours, then get out to have the baby. Or you may decide on a water birth. For information, visit www.waterbirth.org.

Whatever happened to birth plans? Yesterday’s pages of written instructions are giving way to wish lists that outline what expectant moms would like to happen during labor. Here are a few other areas in which women are becoming more flexible about giving birth: Then No fetal monitoring No IV for drugs No epidural Now Sporadic fetal monitoring Heparin lock (a needle is inserted in case you need an IV, but you aren’t attached to anything) “Going with the flow” and seeing how you feel — M.J.H.

HOW would you like to give birth? Planning can help you have the kind of childbirth experience you want. Here are some of the decisions and dilemmas women wrestle with most, and information to put them in perspective.

Scheduling your delivery More women are choosing their baby’s birth date for a variety of reasons, including fear of the unexpected, work considerations and vacation schedules for school-age children. But scheduling an induction or a first-time C-section isn’t without risk—or debate.

Inducing labor with drugs is one way to help ensure that childbirth occurs in a specific 24- to 48-hour period. In 2001, nearly 21 percent of babies were delivered after labor was induced—up from 8 percent in 1989, according to the American College of Obstetricians and Gynecologists (ACOG). This does not mean that inductions are always safe. According to Michael F. Greene, M.D., director of maternal-fetal medicine at Massachusetts General Hospital in Boston, induction increases the chances of a C-section by 50 percent and should only be done when risks of continuing the pregnancy, such as having high blood pressure or being two weeks overdue, exceed the risk posed by inducing labor. “ACOG is against inducing labor just because you want the baby to be a Sagittarius,” Greene says.

Induction isn’t always successful, either. Hormones such as oxytocin are released when labor starts naturally. But administering Pitocin, the synthetic version of oxytocin, does not guarantee that labor will necessarily begin or progress easily. In fact, if Pitocin is given too aggressively, extremely frequent and intense contractions can result.

Some doctors say that women who are determined to schedule labor are better off planning C-sections instead of inductions. This is because a scheduled Cesarean often is easier on the body than a long, induced labor that may end with an emergency C-section anyway.

Having an episiotomy An episiotomy is an incision that widens the vaginal opening so the baby’s head can pass through more easily. For decades, obstetricians routinely performed episiotomies, believing an incision would prevent serious tears and pelvic-floor muscle damage, which can contribute to incontinence. But new research has found that nearly 8 percent of women who have episiotomies develop serious tears, compared with 3.6 percent of women who don’t have them, and that the procedure may increase, not reduce, damage to pelvic-floor muscles. ACOG denounced routine episiotomies in 2000, but some doctors continue to perform them needlessly. An episiotomy is warranted when a forceps or vacuum-suction delivery is needed, when a baby is very large or needs to be delivered quickly. Ask your doctor what her episiotomy rate is and what factors prompt her to perform them. — laurie tarkan

Trying for a VBAC In the early ’90s, when many women learned they could safely deliver vaginally after a prior C-section, the rate of VBACs (vaginal birth after C-section) rose steadily—by 50 percent—until 1997. Then came reports that VBAC increased the risk of uterine rupture, an emergency situation that’s potentially deadly for both mother and baby. The VBAC rate plummeted from 28.3 percent in 1996 to just 12.7 percent in 2002. Research later reported in The New England Journal of Medicine found that the risk for uterine rupture was largely linked to certain induction drugs. Today, many doctors say VBAC is safe, as long as labor is not induced. But the most important precaution is choosing a hospital that is prepared to handle VBAC emergencies. Before attempting a VBAC, consult with your doctor; she’ll take into consideration why you had the prior C-section, the type of incision you had, whether you had a fever afterward and other factors. — L.R.S. Dealing with labor anxiety While just about every pregnant woman feels some anxiety about labor and delivery, 6 percent to 10 percent suffer intense fear that manifests itself as nightmares, physical complaints, difficulty concentrating or other symptoms. If left unchecked, fear and its associated stress can contribute to both early and late deliveries, smaller babies and a higher risk for emergency C-section. What’s more, frightened women may actually experience more discomfort during childbirth, says Alice D. Domar, Ph.D., a Harvard Medical School expert on stress. Prenatal distress also is associated with postpartum depression and difficulty bonding with the baby. The good news is that there are ways to reduce your fear of childbirth. Here are six of them: 1) Track the source Certain experiences can trigger an intense fear of labor; these include past abuse or rape, miscarriage or stillbirth; guilt over an abortion; a previous difficult delivery; and exposure to traumatic labor stories. 2) Don’t wait Deal with your fears at the beginning, not the end, of your pregnancy, recommends Heather Kleber, a certified childbirth educator and doula in San Antonio. 3) Consider therapy In one study, women with an intense fear of labor who underwent cognitive (talk) therapy had shorter labors and fewer unnecessary C-sections than those who didn’t. 4) Tell your doctor Just sharing your fears may help, and your physician may have ideas about how to reduce your anxiety. Also discuss your feelings about medication, laboring positions, episiotomy and similar issues during a prenatal visit 5) Shut out negative stories Don’t watch scary TV shows about childbirth, read horror stories or listen to friends recount the gory details of their labors.

6) Be open-minded about drugs Knowing that effective means of pain relief are available can help lessen your anxiety about labor. — alice lesch kelly

WHAT happens during delivery? Often, the reality of childbirth only slightly resembles movie or TV depictions. Every labor is different, but here's a typical scenario.

The stages of labor Early labor (typically 5–8 hours long) When contractions first begin, your cervix is effacing (thinning) and dilating (opening from to 3 centimeters). On average, it opens about 1 centimeter per hour. Contractions usually are mild at first but build in strength and frequency. Once these start coming every five minutes, most doctors will tell you to go to the hospital. Generally, the nurses will hook you up to an IV to prevent dehydration and to an electronic monitor that measures your baby’s heart rate and your uterine contractions. Your doctor or midwife will do an internal exam to check your progress. You may be offered a mild pain reliever such as Demerol or Stadol; and if you want an epidural, it may be started now (though they are typically started later). Changing positions also can help relieve pain. “I moved around the room a bunch,” says Samantha Denny, 33, of Jackson Hole, Wyo. “I used the hot tub, which really helped my body relax, particularly between contractions. The birthing ball was also very effective. I wasn’t really in bed at all until I had to push, except for the few times when they had to monitor me.” Active labor (2–8 hours) Your cervix will dilate from 4 to 7 centimeters. Contractions will be stronger, longer and closer together, and the breathing and relaxation exercises you learned in childbirth class will come in handy. Transition (15 minutes to 1 hour or longer) Your cervix will dilate from 8 to 10 centimeters. “This is the really intense phase of labor,” says Joan Edwards, M.N., C.N.S., assistant clinical professor at Texas Women’s University in Houston. “It’s when women say things like, ‘I can’t do this anymore!’” Swearing up a storm or becoming angry at your husband (and vowing never to have sex again) are perfectly normal during this time.

Pushing (a few minutes to 3 hours) When you’re dilated 10 centimeters, it’s time to push. You feel lots of pressure in the rectal area, as if you’re trying to pass a bowel movement. Pushing can be exhausting, but many women find it’s a relief to start. “I thought the pushing part was pretty easy, especially since the epidural had just kicked in,” says Courtenay Manes Labson, 37, of Chevy Chase, Md. “It felt productive, whereas labor prior to that point had felt more reactive. I also think being in good shape physically made pushing more doable.” As the baby’s head first begins to show, your doctor may perform an episiotomy if she feels it’s necessary.

After the baby is born Within 30 minutes you'll be asked to push again to deliver the placenta, which usually comes out easily. If you've had an episiotomy, your doctor will then stitch you up. And you'll get to hold your baby for the first time. - A.L.K.

If you have a C-section Whether or not your C-section is planned, here’s roughly what you can expect. > A nurse will start an IV containing saline solution and, in some cases, an antibiotic. Unless the C-section is an emergency, the anesthesiologist will administer an epidural so you won’t feel anything below your belly button (though you’ll be fully awake). Otherwise, you may receive a general anesthetic. > Your doctor will drape the area around your belly, then cut through the skin, muscles, uterus and amniotic sac. “You feel almost nothing—maybe a little pressure and some tugging,” says Gloria Bachmann, M.D., chief of the OB-GYN Service at the Robert Wood Johnson University Hospital in New Brunswick, N.J. Minutes later, the doctor will lift the baby out and bring her up to your head for you to see. Then the doctor will remove the placenta and stitch you up. The entire process will take 40 to 90 minutes. > In the recovery room, nurses will monitor your blood pressure, breathing and heart rate. (You might become nauseated and start vomiting at this point; this is normal.) After an hour or so, you’ll be moved to your room and reunited with your baby, and you’ll probably be able to breastfeed at this time. > In the following days and perhaps weeks, you’ll experience gas pains and pain at the incision site. Like women who deliver vaginally, you’ll need to wear pads for several weeks to absorb the blood-tinged fluid that will flow from your uterus as you recuperate. — a.l.k.

What is fetal distress? Though it has no universally agreed-upon medical definition, fetal distress is generally characterized as a slowing (“deceleration”) of the baby’s heart rate at times during labor when it shouldn’t, or a deep slowing for longer periods than most doctors are comfortable with. In many cases, doctors have plenty of time to consider their options, which include vacuum extraction, delivery with forceps or simply untangling the umbilical cord from around the baby’s neck. But when fetal distress occurs suddenly—the uterus is rupturing, for example—doctors have only minutes to get the baby out to avoid possible brain damage or even death. When there’s any likelihood of this, doctors tend to err on the side of caution and perform a C-section. Sometimes babies who are stressed in utero pass their first stool (meconium) while still in the birth canal. If it’s inhaled, a lung infection or pneumonia can result. In such cases, the baby’s mouth is suctioned as soon as the head is delivered. — L.R.S.

3 tips for an easier labor 1. Set the mood A dark, quiet environment is ideal, so ask for dim lights and minimal noise. 2. Stuff a sock Bring a tube sock with three tennis balls in it and have your partner or someone else roll them up and down your back to relieve pain. 3. Get on the ball Drape your upper body faceup over a large exercise ball to relieve back pain. Or sit on it with your legs apart to relax the pelvic area. — lu hanessian